Last Days of Surgery

Brief Overview

This week we continued hospital rounds in the surgery unit. We had one more day at Universitas Hospital, then went to Pelonomi for the remainder of the week to get experience in a different location. These mornings we went on rounds in the wards and then observed some clinic visits. We were also on call at Pelonomi Thursday evening after class until 11pm. We only saw two patients while there. One was not in a stable enough state to have his operation, and the other was an appendectomy. Lecture topics have included surgery, health policy and service delivery, ophthalmology, obstetrics and gynecology, and trauma.

Clinical Rounds

Our first day of rounds, none of us knew what to expect. We arrived and quickly began following a doctor from bed to bed. At each bed, registrars had to present the patient’s history, diagnosis, and treatment to the doctor. Then, the doctor would question both the registrars and the students. There were about 4-6 patients per room, so there was little privacy. There were some very interesting cases, however, since these patients were brought in for the 5^th year clinical exams that had just ended. We saw a 98 year old man with breast cancer, many hernia patients, breast cancer patients, and patients with thyroid conditions. It was interesting that the doctor never used gloves, even when undressing wounds and drawing blood. We later went to the endocrine clinic. We sat in on a consultation about a patient’s thyroid condition, but I was unable to understand much because they were speaking Afrikaans.

Rounds in Pelonomi were only slightly different. We were accompanied by some 4^th year medical students and two doctors. These doctors were much more interactive with the students. When they did not know the answers to his questions, he would make them find the answers and report their findings to him the following day, rather than tell them the answer. The students say they’ve learned much better that way. When they did know answers, he asked continually more detailed or challenging questions to really prepare them to be doctors. The students were also very helpful with explaining things to us. One of the fourth year students even taught me how to examine a parotid mass on a patient. The very next day, the doctor had to use a translator to tell this woman that the mass was cancerous and the removal of the tumor would compromise her facial nerve, leaving one side of her face paralyzed. He wanted the patients to see how to effectively deliver bad news, as this is a necessary skill for all physicians. At the clinic, the doctor took about a half hour to let the 4^th year students present their “homework” from the previous day and explain more to them about their patients. Then, we saw two consultations. The doctor was extremely compassionate toward his patients and addressed their concerns and desires regarding their treatments.

On Call

After class on Thursday, we went back to Pelonomi to be on call until 11pm. It was very slow that night. We saw only two patients. The first was a middle-aged man with AIDS. He needed a surgery for an intestinal blockage, but the doctors could not operate due to the severity of his AIDS. The students said this is quite normal, since most of their patients are HIV positive (very different from the US). They’ve been taught to assume all patients are HIV positive until proven otherwise. If a doctor or student gets pricked, they are started on immediate ARV treatment for one month. We later saw a patient that presented with abdominal pain. It was fascinating to be there for the entire process of trying to make a diagnosis. It first began with eliminating ectopic pregnancy. We were told to assume every woman is pregnant until proven otherwise, and that every pregnancy is ectopic unless proven otherwise. We learned a lot about the different blood, urine, and radiological tests that are done. Even with all of the tests, it was unsure what her problem was, so they had to do an exploratory abdominal surgery. It ended up that she had appendicitis, so they simply had to remove it. We saw her the next morning, and she was recovering well.  

Lectures

The surgery lecturer handed out an outline of everything that is most important in each chapter to help guide the students. He is 83 years old and was the first trauma surgeon in SA, so it was very interesting to hear his advice and opinions. He highlighted the power of observation, listening to the patient, managing time, and asking open questions. He also spoke much about how different each individual patient is and the danger of making generalizations. Finally, he taught about establishing a trusting and respectful relationship with the patient by touching their hand before continuing with the rest of the examination.

The ophthalmology lecturer was substituting for the normal lecturer. She mainly read off of the slides and finished very quickly. The health policy and service delivery lecture was fantastic (probably because I’m more interested in public health than most of the medical students). He was very funny and interactive. He probed the students to think beyond the principles that seemed like common sense upon first glance. For example, he made them define the term “healthcare system.” At the end, he reviewed health legislature in the past decade in SA, but he went through it very quickly. The main things were the ability of children to consent to abortion at age 12, the implementation of a national health insurance plan, ARV roll out plans, and the role of the government in sustaining the private health care sector in SA.  The obstetrics and gynecology lecture was very interesting, especially since I’ll be in that department for clinical rounds next week. She was very effective because she showed the logic behind all the changes that happen during pregnancy.

The trauma lecture was two hours long. He began with a history of trauma, starting with Cain and Abel in the Bible, the Aztecs, ancient Chinese medicine, early ambulances, all the way to the current state of emergency medicine and trauma. He also mentioned ethics, specifically regarding prolonging one’s life and whether the patient will still have dignity once they recover. He included law as well, by teaching about prevention. For example, laws against drinking and driving help prevent motor vehicle accident trauma. This lecture also included some physics, treatment techniques, and information about providing psychological support for patients and their families. At the end, he predicted that in the future, more trauma will be due to terrorism, and biological or nuclear agents, as well as natural disasters. Additionally, he commented on the importance of technology, as the hospitals are now moving away from paper charts and toward electronic systems.

Clinical Education Facts

• The entrance exam is a general test covering math, reading, science, and writing; it takes a total of six hours.
• The students take OSCE exams, in which they see a picture of a condition. They must describe what they see, diagnose the condition, tell what other causes are possible, and outline what types of treatments may be used.
• UFS has an anatomy and pathology museum for students to utilize when studying. It was amazing to see how many different specimens they had--including embryos from every stage of pregnancy.
• The students joke that 3rd years are "medical spies," because they don't know anything and are just looking around, taking in information. The 4th years are "medical tourists," because they are observing everything. The 5th years are "medical slaves," because now they are expected to do everything they've learned and seen the past two years.